Adenoidectomy is one of the most commonly performed operations in children. Pioneered in the 19th century by Hans Wilhelm Meyer, the procedure has radically evolved over the last century and a half and now has a low, associated morbidity and a robust evidence base. It is primarily performed as treatment of otitis media with effusion and obstructive sleep apnea in children.
The adenoid is a proliferation of lymphoid tissue lining the roof and posterior wall of the nasopharynx, forming the superior aspect of Waldeyer’s lymphatic ring. Identifiable from 6 weeks gestation, it receives its blood supply from branches of the facial and maxillary arteries, and the thyrocervical trunk. The adenoid enlarges rapidly during early childhood and reaches its largest size in 7-year-olds before regressing. A relative mismatch between an enlarged adenoidal pad and a small nasopharynx in the pediatric population can result in choanal obstruction, leading to sleep-disordered breathing and obstructive sleep apnea. Obstruction of the Eustachian tube orifice, in conjunction with the presence of an increased bacterial load in the adenoid, is thought to produce a biofilm infection implicated in the pathogenesis of otitis media with effusion.
The main, evidence-based indications for adenoidectomy are the treatment of otitis media with effusion and obstructive sleep-disordered breathing in children. The latter procedure is often performed in conjunction with tonsillectomy in cases of gross tonsillar hypertrophy, or concurrent history of recurrent tonsillitis meeting the Paradise criteria.
Less frequent indications for adenoidectomy are in the holistic management of rhinosinusitis, hyposmia or anosmia, and suspected malignancy. The decision to operate should always be based on a clear positive history, clinical examination, and appropriate investigations. In otitis media with effusion, this includes audiometry and tympanometry, and in cases of sleep-disordered breathing, polysomnography is recommended.
Whilst there are no absolute contraindications to adenoidectomy, careful consideration must be given to palatal insufficiency. Individuals with known cleft palate or occult submucosal cleft palate are at a significantly increased risk of developing velopharyngeal insufficiency following adenoidectomy which can result in persistent hypernasal speech and nasal regurgitation. In such individuals a partial adenoidectomy limited to the lower third of the choana has been proposed. Other relative contraindications to adenoidectomy include significant bleeding diathesis and active infection.
A range of instruments is currently used to carry out adenoidectomy. These instruments include monopolar suction diathermy, curettage, and more recently endoscopically-guided micro-debrider, coblation, and laser techniques.
Adenoidectomy can be performed with the support of an operating department practitioner, a scrub nurse, and an anesthetist.
Following induction and intubation, the patient is laid supine with an appropriately-sized shoulder bolster to facilitate neck extension. If myringotomy and grommet insertion are to be performed concurrently, this usually precedes adenoidectomy; whereas, concurrent tonsillectomy tends to be performed after adenoidectomy and subsequent (if required) packing of the postnasal space to facilitate hemostasis.
A Boyle-Davis gag is inserted and opened to achieve good visualization of the oropharynx, and Draffin rods are attached to maintain an optimal position. The soft palate should always be palpated for a submucosal cleft, and the postnasal space may also be palpated to assess adenoid size.
A nasal suction catheter is introduced, and its tip is withdrawn from the oropharynx. The 2 ends are then clipped under moderate tension adjacent to the alar cartilage to retract the soft palate anteriorly. A tonsil swab may be positioned between the catheter and nose to prevent pressure necrosis.
A wide range of techniques for adenoidectomy exist, including laser ablation, coblation, endoscopic excision, and power-assisted (microdebrider) excision. The 2 most commonly performed techniques are curettage and monopolar suction diathermy. Some surgeons favor monopolar suction diathermy for its simplicity, low post-operative hemorrhage rate, and comparable outcomes to more expensive and complex emergent techniques.
Monopolar Suction Diathermy
The custom monopolar suction diathermy device is bent to 70 to 90 degrees approximately 2 centimeters from its tip and the stylet removed. Under indirect visualization with an anti-fogged laryngeal mirror suction-diathermy (current 35 to 38 W) is carried out systematically, superiorly to inferiorly, from the choanal to the velopharyngeal portion of the adenoid. Lateral adenoidal tissue can be suctioned medially before ablation, avoiding trauma and scarring of the tubal cushion. The procedure is completed when a comprehensive view of the choana is achieved, the nasopharynx has a smooth contour and hemostasis ensured. Nasal packing is rarely required.
An adenoid curette is introduced to the postnasal space and engages with the adenoid pad. A dental mirror can be used to facilitate indirect visualization and confirmation of positioning. The adenoids are removed superior to inferiorly in a single, firm movement, with the head stabilized by the non-dominant hand. The process may be repeated, and the nasopharynx re-examined either by palpation or with a mirror to ensure completeness of excision. The post nasal space may be packed with swabs to achieve hemostasis while a tonsillectomy is performed. These must be removed at the end of the procedure.
On completion of adenoidectomy, it is essential to suction any clots from the postnasal space using a nasal suction catheter and to ensure that hemostasis has been achieved. Care must be taken when removing the gag to ensure that the endotracheal tube has not herniated into the blade, to prevent inadvertent extubation.
Pain is self-limiting, and a short course of simple analgesics such as paracetamol and non-steroidal anti-inflammatory medications is usually sufficient.
An altered voice is usually the resolution of preexisting hyponasal speech and is often seen as a benefit rather than a complication.
Adenoid regrowth is noted in a small number of patients, and occasionally a revision adenoidectomy is necessary.
Dental trauma and minor injuries to the lips and tongue can occur following adenoidectomy and tonsillectomy. The surgeon must enquire preoperatively about loose teeth and fillings, and exercise caution when introducing and opening the Boyle-Davis mouth gag to minimize these risks.
Bleeding is rare, and with the widespread adoption of diathermy and techniques involving direct visualization, rates have declined to as low as 0.07%. Management of bleeding involves admission and packing of the postnasal space. Intraoperative bleeding can result in the formation of a "coroner's" clot in the nasopharynx that can dislodge and result in fatal aspiration. For this reason, it is mandatory to suction the post nasal space before completing the surgery.
Atlantoaxial subluxation (Grisel syndrome) is a rare but serious complication following adenoidectomy. Pre-existing laxity of the anterior spinal ligament (often seen in Down syndrome) and excessive use of diathermy are recognized risk factors. Management consists of analgesia, immobilization, and neurosurgical intervention in refractory cases.
Long-term velopharyngeal insufficiency is rare, occurring in between 1 in 1500 and 1 in 10,000 cases. It results in hypernasal speech and nasal regurgitation. Risk factors include a known cleft palate or an occult submucosal cleft palate. A partial adenoidectomy retaining tissue at the velopharyngeal junction may be considered in these cases to minimize the risk. Rarely, reconstructive surgery is performed to improve severe speech and swallowing impairment.
Glue ear and sleep-disordered breathing are complex disease processes that can have a profound impact on the psychological, social, and biological development of a child, and an interprofessional approach to management is key to achieving optimal outcomes. While general practitioners will often refer directly to otolaryngologists, the involvement of pediatricians to assess global development, the presence of any underlying systemic conditions, and in the perioperative care of children is often essential.
Respiratory and sleep medicine specialists are frequently invaluable in the diagnosis and treatment of sleep-disordered breathing and associated respiratory illness, and in arranging polysomnography. Audiologists perform audiometry and tympanometry and are therefore essential in diagnosing glue ear and assessing the degree of conductive hearing loss.
Perioperative management requires excellent communication between surgeon and anesthetist, particularly in relation to determining whether surgery should be planned as a day case or with an overnight stay for monitoring for oxygen desaturations. Intraoperative communication between surgeon and anesthetist is crucial during the insertion and removal of the mouth gag which if carelessly applied can inadvertently compress or extrude the endotracheal tube.
Throughout any admission or clinic, close involvement of pediatric nurses is vital to ensure that patients are stable and to pick up any early signs of deterioration. Finally, optimal care in the management of otitis media with effusion in patients with cleft palate or Down syndrome is achieved through an interprofessional team with appropriate expertise in the condition (Level V).